Abstract of Dissertation

Agency : Insurance, Total Quality Management System, Standard Operating Protocols, Clinical Quality Matrix

Objective : • To understand thoroughly the process flow of a health insurance claim in GMC, Ajman. • To examine the issues and challenges faced by the insurance department of hospital. • To develop an understanding of the claim management with Redefining the TQM

Background : The proliferation of various healthcare technologies and increase in the cost of care has necessitated the exploration of health financing options to manage problems arising out of increasing healthcare costs. However, one of the problems with the private sector has been its uncontrolled and unregulated expansion .Problems of billing system and under-reporting have resulted into lack of information. Absence of regulation and lack of standardization of the private healthcare market has led to high claim ratio .This also leads to problem of the moral hazard resulting into over billing. Private hospitals, in their quest to generate maximum revenue, perform medical procedures which may not be necessary on patients covered by medical insurance policy. The insurance companies insist on standardization of protocols for Insurance Department serving from hospital end. As a need of hour apart from the clinical departments the insurance department also needs to be standardized with highly efficient Total Quality Management System for its administration & operational improvement. GMC, Ajman is a world-class medical institution offering quality and affordable specialized superior medical care complemented by a warm and personalized human touch to the members of most of the insurance companies in UAE. There department is staffed by a team of expert professionals who assist in administering to the needs and queries of patients holding insurance cards. Insurance companies on direct billing: Abu Dhabi National Insurance Company, Al Buhaira Insurance Company, Al Ittihad Al Watani Insurance Company, Al Khazna Insurance Company, Alliance Insurance Company, Arabian Scandinavian Insurance Company, Axa Insurance, American Life Insurance Company "ALICO", Ahlan Care, Al Dhafra National Insurance, ACE Life, AlMadallah Health Care Management, Daman Insurance, EKLAIM, Fathima Healthcare Management Services UAE, FMC, Focus, GLOBE MED, Globel Net, Aetna Health Service, "Goodhealth", Healthnet Insurance, Interglobal, Lebanese Insurance Company, MEDISERVE, Mednet and all the Insurance Companies listed under Mednet, MIPOL, MSH, NAS Admin Services, Next Care, Neuron, P.M care "AVITA" and Oman Insurance Company.

Methodology : Study Area: GMC, Ajman is rendering third party payment facilities to the patients who are the health insurance policy holders. Study Design: A Qualitative Retrospective Observational Study was carried out on the insurance department & claims processing of the patients who have the health insurance policy both in-patient & outpatient. Sample Size: A record of patients coming with insurance coverage, services rendered and claims processed over a period of three months was taken as the sample. Data Analysis: The collected data was analyzed manually as well as by using lean healthcare tools & statistical methods. The proper assessment of factors related to the claim process and the issues confronted by the hospital were analyzed.:

Recommendations : The total process flow were made and analyzed through Value Steam Mapping, Various gaps were figured and improvements were suggested. The total quality management was redefined by preparing Standard Operating Protocol for the Department, Improving internal HIMS, Improving the process improvement, benchmarking the rejection rates, planning the new organogram for the department, re-defining the manpower planning & layout plan for departmental space utilization